Diagnosis Of Pelvic Floor Disorders Research Articles

Anorectal manometry for the diagnosis of pelvic floor disorders in patients with hypermobility spectrum disorders and hypermobile Ehlers-Danlos syndrome

IntroductionFunctional gastrointestinal disorders (FGID) including impaired rectal evacuation are common in patients with Hypermobility Spectrum Disorder (HSD) or Hypermobile Ehlers-Danlos Syndrome (hEDS). The effect of connective tissue pathologies on pelvic floor function in HSD/hEDS remains unclear. We aimed to compare clinical characteristics and anorectal pressure profile in patients with HSD/hEDS to those of age and sex matched controls.MethodsWe conducted a retrospective review of all FGID patients who underwent high resolution anorectal manometry (HR-ARM) and balloon expulsion test (BET) for evaluation of impaired rectal evacuation. Patients with HSD/hEDS were age and sex matched to a randomly selected cohort of control patients without HSD/hEDS. An abnormal BET was defined as the inability to expel a rectal balloon within 2 minutes. Wilcoxon rank sum test and Fisher’s exact test were used to make comparisons and logistic regression model for predictive factors for abnormal evacuation.ResultsA total of 144 patients (72 with HSD/hEDS and 72 controls) were analyzed. HSD/hEDS patients were more likely to be Caucasian (p < 0.001) and nulliparous. Concurrent psychiatric disorders; depression, and anxiety (p < 0.05), and somatic syndromes; fibromyalgia, migraine and sleep disorders (p < 0.001) were more common in these patients. Rate of abnormal BET were comparable among the groups. HDS/hEDS patients had significantly less anal relaxation and higher residual anal pressures during simulated defecation, resulting in significantly more negative rectoanal pressure gradient. The remaining anorectal pressure profile and sensory levels were comparable between the groups. While diminished rectoanal pressure gradient was the determinant of abnormal balloon evacuation in non HSD/hEDS patients, increased anal resting tone and maximum volume tolerated were independent factors associated with an abnormal BET in HSD/hEDS patients. Review of defecography data from a subset of patients showed no significant differences in structural pathologies between HSD/hEDS and non HSD/hEDS patients.ConclusionsThese results suggest anorectal pressure profile is not compromised by connective tissue pathologies in HSD patients. Whether concurrent psychosomatic disorders or musculoskeletal involvement impact the pelvic floor function in these patients needs further investigation.

Three-dimensional high-resolution anorectal manometry: A comparative pilot study with X-ray defaecography

Three-dimensional high-resolution anorectal manometry (3DHRAM) is a new technique that can explore anorectal disorders and provide interesting topographic data for the diagnosis of pelvic floor disorders such as paradoxical puborectalis syndrome (PPS). Our object was to evaluate whether 3DHRAM can reliably diagnose PPS already diagnosed with X-ray defaecography, which is considered to be the gold standard. All patients being tested in our department for dyschezia by 3D-HRAM and X-ray defecography were eligible for the study. The 3DHRAM results were compared with X-ray defecography. The sensitivity, specificity, and positive and negative predictive values were calculated for various 3DHRAM criteria to propose a diagnostic strategy for PPS. Twenty-three patients presented with PPS on X-ray defaecography. On 3DHRAM, according to our diagnostic strategy, the kappa value was 0.706, with a positive predictive value of 71.88% [95% CI, 53.02-85.60], a specificity of 80.43% [95% CI, 65.62-90.13], a sensibility of 95.83% [95% CI, 76.98-99.78], and area under curve value was 0.922. In this study, 3DHRAM was used to diagnose PPS with the same degree of reliability as X-ray defaecography, and we confirmed its use in the diagnosis of pelvic floor disorders. Further studies will be necessary to define classifications for these new anatomic data from 3DHRAM.

The Experiences of Women who Live with Pelvic Floor Disorders: A Qualitative Study.

ABSTRACTBackground: Pelvic floor disorders (PFDs) are common and complicated problems that occur in women with different ages and cultural backgrounds and affect various dimensions of their life. Because of the dearth of information about how the Iranian women manage these disorders, this study was conducted to explore the experiences of women who live with PFDs.Methods: This qualitative study was conducted between 2018 -2019 on women who referred to the clinics of Mashhad educational hospitals . 25 deep and semi-structured interview with 22 patients with PFDs was done. They were recruited through a purposive sampling method among women with diagnosis of PFDs. Data were analyzed using conventional content analysis adopted by Graneheim and Lundman and organized using the MAXQDA software (Ver.10).Results:The analysis of the data led to the emergence of a theme of “Acceptance and Tolerance”, including four categories: “Trying to adopt sexual conflicts”, “ Concealing the disease”, “Trying to modify the lifestyle”, and “Controlling negative emotions”, and 15 sub-categories.Conclusion: This study provides an insight into self-management strategies for different aspects of challenges faced by women with PFDs.They try to resolve, conceal, modify, and control some issues to accept and tolerate their disease. By identifying self-management strategies, care providers can design and implement counseling, educating and supporting interventions, and also a program through which the patients help and guide each other.

Magnetic imaging defecography results are comparable to high-resolution manometry and conventional X-ray defecography in the assessment of functional pelvic floor disorders.

X-ray defecography or magnetic resonance defecography (MRD) and high-resolution anorectal manometry (HR-ARM) are essential for the diagnosis of pelvic floor disorders (PFD). However, there is only scarce information available about the accuracy of MRD in the functional assessment of the pelvic floor. The aim of this study was to examine the accuracy of MRD in the diagnosis of pelvic floor disorders by examining the intra-test agreement with x-ray defecography and HR-ARM in patients with PFD. The study population included adults referred to our institution in January 2018-February 2020 for MRD as part of their evaluation of PFD. The MRD results were compared with X-ray defecography and HR-ARM. Forty-two patients were included in the study (36 female, 86%, mean age 56.9years ± 15.8, range 19-86years). When compared to X-ray defecography, the sensitivity of MRD for the evaluation of normal rest and squeeze pressures was high (0.83 and 1, respectively). High sensitivity rates were observed for the detection of pelvic organ prolapse and pelvic floor dyssynergia (0.84-1). When compared to HR-ARM, the sensitivity of MRD for the evaluation of squeeze and dyssynergia was very good (0.92and 1, respectively), and good for the evaluation of rest pressure (0.6). Inter-test agreement was high (0.5, 0.6, 0.6 for rest, squeeze and dyssynergia). Excellent rates of sensitivity as well as almost perfect intra-test agreement was found between abnormal balloon expulsion test and the diagnosis of dyssynergia and pelvic organ prolapse on MRD (1, 0.81). This study demonstrated substantial diagnostic agreement between HR-ARM and MRD in the diagnosis of pathological etiologies for functional pelvic floor disorders, mainly obstructed defecation syndrome.

The Role of MRI in the Diagnosis of Pelvic Floor Disorders.

This article provides an overview of MRI as a dynamic imaging modality as well as recent updates on the role of MRI in the evaluation of female pelvic floor disorders, including pelvic organ prolapse (POP), rectal prolapse, and defecatory dysfunction. Pelvic floor disorders in women are common, and demand for treatment is high. Recently, multidisciplinary guidelines for dynamic MRI have been published to reflect this need. Despite criticisms that MRI is an expensive modality, cost-analysis studies are demonstrating utility for MRI in surgical decision-making trees for patients at risk for treatment failure after POP repairs. Novel measures such as anterior pelvic area and levator volumes are being used to predict and study patients with and at risk for POP. Recent standardized radiographic guidelines as reviewed in this paper will likely lead to improved reproducibility of dynamic MRI techniques across institutions, making complex pelvic floor assessment increasingly accessible to patients while creating opportunities for novel and collaborative research.

Rectal intussusception: can high resolution three-dimensional ano-rectal manometry compete with conventional defecography?

Three-dimensional high-resolution anorectal manometry (3DHRAM), used for exploring anorectal disorders, was recently developed, providing interesting topographic data for the diagnosis of pelvic floor disorders such as excessive perineal descent. The aim of our study was to define a diagnostic strategy based on selected 3DHRAM parameters to identify rectal intussusceptions (RI), considering conventional defecography (CD) as the gold standard. All patients referred to our center in the previous 6months for 3DHRAM to explore fecal incontinence or constipation, and who previously achieved CD, were eligible. 3DHRAM results were obtained for all classical parameters and the presence of a narrow band of high pressure in the anal canal during attempted defecation, which was recently found to be associated with RI in some studies. The sensitivity, specificity, and positive and negative predictive values were calculated for various 3DHRAM criterion in order to propose a diagnostic strategy for RI. Twenty-six patients (66%) presented with RI on CD. On 3DHRAM, according to our diagnostic strategy, the most relevant manometric criterion for the diagnosis of RI was the association of an anterior additional high-pressure area and an excessive perineal descent, with a positive predictive value of 100% [81.5-100], a specificity of 100% [75.3-100] and a sensibility of 69.2% [48.2-85.7]. In this study, 3DHRAM was used to diagnose RI, and we confirmed its use in the diagnosis of pelvic floor disorders. Further studies will be necessary to define classifications for these new anatomic data from 3DHRAM.

ID 49 – Electrophysiological tests in diagnosis of pelvic floor disorders

Objective The aim of this study was to examine whether pelvic floor electrophysiological (PFE) tests contribute to diagnosis of pelvic floor disorders. Methods Clinical information and PFE data of 18 patients consecutively referred for assessment of possible pelvic floor disorders, were analysed retrospectively. The results of pudendal somatosensory evoked potentials (SEP), penilo/cliterocavernosus reflex, electromyography (EMG) of external anal sphincter (EAS) muscle were analysed. The clinical course of the patients and the influence of the electrophysiological results to clinicians’ decision were reviewed from patient files. Results Ten of the 18 patients had abnormal PFE tests showing pudendal neuropathy, and all 10 had delayed latencies or absent responses of the penilo/cliterocavernosus reflex. EMG of EAS was abnormal in 8 and pudendal SEP in 2 patients. For 10 patients, the electrophysiological assessment contributed to the diagnosis by confirming the referral theory of pelvic floor disorder. For the remaining patients the assessment enabled the clinician to change the diagnosis, initiate further examination, or treatment. Conclusion Pelvic floor electrophysiology may contribute to the diagnosis of pelvic floor disorders. Penilo/cliterocavernosus reflex is suggested to be a sensitive test. Key message Electrophysiological tests have an impact on the diagnosis or further course of pelvic floor disorders.

The Role of Tridimensional Dynamic Ultrasound for Pelvic Floor Evaluation

IntroductionDynamic endoanal ultrasound has emerged in recent years as a test that could replace the now existing tests in the diagnosis of pelvic floor disorders. The aim of this paper is to determine the usefulness of echodefecography in the diagnosis and evaluation of patients with symptoms of anorrectal obstruction, and show the results obtained after its implementation in a pelvic floor unit, as a complementary tool that could replace conventional defecography. MethodsIn this retrospective study we analysed 66 patients with a mean age of 55 years (19–83), 61 women (92%). All dynamic ultrasound was performed in 3 dimensions and was correlated with symptoms and physical findings in the consultation. A descriptive and inferential study was performed to find a kappa correlation between physical examination and echodefecography. ResultsThe reasons for consultation were: Anorrectal obstruction syndrome 36 patients (54.5%), pelvic organ prolapse 27 patients (40.9%), and anorrectal obstruction syndrome along with pelvic organ prolapse 3 patients (4.5%). The correlation of the 2 groups indicated that echodefecography diagnosed more patients with grade III rectocele, enteroceles, and anismus than the combination of scan-ultrasound-manometry-proctoscopy (Kappa 0.26, 0.38 and 0.21, 95% CI: from 0.07 to 1.00, 0.15 to 1.00 and from 0.12 to 1.00, respectively) (P<.001). Conversely, echodefecography diagnosed less perineal descense (Kappa 0.28, 95% CI: 0.12–1.00). ConclusionsDynamic anal ultrasonography may have a role as a complementary test in patients with pelvic floor disorders, achieving diagnoses that would go undetected by inspection, physical examination and manometry.

B‐spline Based Multi‐organ Detection in Magnetic Resonance Imaging

AbstractIn the context of the female pelvic medicine, non‐invasive magnetic resonance imaging is widely used for the diagnosis of pelvic floor disorders. Nowadays, in the clinical routine, diagnoses rely largely on human interpretation of medical images, on the experience of physicians, with sometimes subjective interpretations. Hence, image correlation methods would be an alternative way to assist physicians to provide more objective analyses with standard procedures and parametrisation for patient‐specific cases. Moreover, the main symptoms of pelvic system pathologies are abnormal mobilities. The finite element model simulation is a powerful tool for understanding such mobilities. Both the patient‐specific simulation and the image analysis require accurate and smooth geometries of the pelvic organs. This paper introduces a new method that can be classified as a model‐to‐image correlation approach. The method performs fast semi‐automatic detection of the bladder, vagina and rectum from magnetic resonance images for geometries reconstruction and further study of the mobilities. The approach consists of fitting a B‐spline model to the organ shapes in real images via a generated virtual image. We provided efficient, adaptive and consistent segmentation on a dataset of 19 patient images (healthy and pathological).

Utilidad de la ecografía dinámica tridimensional en el estudio del suelo pélvico

IntroductionDynamic endoanal ultrasound has emerged in recent years as a test that could replace the now existing tests in the diagnosis of pelvic floor disorders. The aim of this paper is to determine the usefulness of echodefecography in the diagnosis and evaluation of patients with symptoms of anorrectal obstruction, and show the results obtained after its implementation in a pelvic floor unit, as a complementary tool that could replace conventional defecography. MethodsIn this retrospective study we analyzed 66 patients with a mean age of 55 years (19-83), 61 women (92%). All dynamic ultrasound was performed in 3 dimensions and was correlated with symptoms and physical findings in the consultation. A descriptive and inferential study was performed to find a kappa correlation between physical examination and echodefecography. ResultsThe reasons for consultation were: Anorrectal obstruction syndrome 36 patients (54.5%), pelvic organ prolapse 27 patients (40.9%), and anorrectal obstruction syndrome along with pelvic organ prolapse 3 patients (4.5%). The correlation of the 2 groups indicated that echodefecography diagnosed more patients with grade III rectocele, enteroceles, and anismus than the combination of scan-ultrasound-manometry-proctoscopy (Kappa 0.26, 0.38 and 0.21, 95% CI: from 0,07 to 1.00, 0.15 to 1.00 and from 0.12 to 1.00, respectively) (P<.001). Conversely, echodefecography diagnosed less perineal descense (Kappa 0.28, 95% CI: 0.12 to 1.00). ConclusionsDynamic anal ultrasonography may have a role as a complementary test in patients with pelvic floor disorders, achieving diagnoses that would go undetected by inspection, physical examination and manometry.

Beckenbodendysfunktion aus chirurgischer Sicht

Pelvic floor disorders present very differently with regard to symptoms and manifestation. Both diagnostic and treatment options require specific experience and an interdisciplinary approach. Diagnostic work-up is primarily based on medical history, physical examination and procto-rectoscopy. Furthermore, endosonography and perineal sonography have also gained importance. In almost all cases following these basic examinations conservative therapy options should be considered. As the interdisciplinary concept is very important, for careful diagnosis of pelvic floor disorders it became crucial to find an adequate form of treatment. Every decision for surgical therapy should not only focus on the results of previous examinations but should also consider the individual situation of each patient. In pelvic floor disorders a large variety of symptoms are confronted with a vast number of different and often highly specific procedures. The decisions on who to treat and how to treat are not only based on individual patient requests and desires but also on the experience and preference of the surgeon.

Female pelvic floor dysfunction—an imaging perspective

Female pelvic floor dysfunction encompasses a range of morbidities, including urinary incontinence, female pelvic organ prolapse, anal incontinence and obstructed defecation. Patients often present with symptoms covered by several specialties including gastroenterology, colorectal surgery, urology and gynecology. Imaging can therefore bring clinicians from multiple specialties together by revealing that we frequently deal with different aspects of one underlying problem or pathophysiological process. This article provides an interdisciplinary imaging perspective on the pelvic floor. Modern pelvic floor imaging comprises defecation proctography, translabial and endorectal ultrasound, and static and dynamic MRI. This Perspectives focuses on the potential use of translabial ultrasound, including 3D and 4D applications, for diagnosis of pelvic floor disorders. Over the next decade, pelvic floor imaging will most likely be integrated into mainstream diagnostics in obstetrics and gynecology and colorectal surgery. Using imaging to facilitate communication between different specialties has the potential to greatly improve the multidisciplinary management of complex pelvic floor disorders.

Dynamic Anal Endosonography and MRI Defecography in Diagnosis of Pelvic Floor Disorders: Comparison With Conventional Defecography

Pelvic floor disorders are frequent, especially in women. Surgeons need more information on the accuracy of available diagnostic techniques to make therapeutic decisions. This study aimed to compare the accuracy of dynamic anorectal endosonography and dynamic MRI defecography with conventional defecography as the criterion standard in the diagnosis of pelvic floor disorders. We used a prospective crossover design in which patients underwent each procedure in random order within the same month. Investigations were conducted at a regional referral center in Marseille, France. Women with dyschezia who were undergoing diagnostic evaluation were eligible. Dynamic anorectal endosonography, dynamic MRI, and conventional defecography were performed in all patients by 3 blinded operators. The accuracy of dynamic anorectal endosonography and dynamic MRI in the diagnosis of pelvic floor disorders was assessed by calculating sensitivity, specificity, positive and negative predictive values, correlation coefficients, concordance rates, and the Cohen κ statistic, with conventional defecography used as the criterion standard. The study comprised 56 women with a mean age of 50.7 (SD, 12.5) years. No significant differences were observed between dynamic anorectal endosonography and dynamic MRI in the number of patients with rectocele (P = .49), perineal descent (P = .11 when dynamic anorectal endosonography measured descent of the puborectalis muscle; P = .27 for bladder descent), or enterocele (P = .78); no differences were found between these techniques in sensitivity, specificity, or positive and negative predictive values. Diagnostic concordance with conventional defecography as the standard did not differ significantly between dynamic MRI and dynamic anorectal endosonography: Concordance rates for dynamic anorectal endosonography were 75% for rectocele, 64% for perineal descent, and 91% for enterocele (no rectal intussusception was found with dynamic anorectal endosonography); concordance rates for dynamic MRI were 82% for rectocele, 57% for perineal descent, 93% for enterocele, and 55% for rectal intussusception. Significantly more internal anal sphincter defects were found with dynamic anorectal endosonography than with dynamic MRI defecography: 21 patients (37.5%) vs 12 patients (21.4%); P = .02. Patient tolerance was significantly better for dynamic anorectal endosonography than for dynamic MRI (P = .002) or conventional defecography (P = .005). Most patients said they would choose dynamic anorectal endosonography (72.1%) rather than dynamic MRI (25.6%) or conventional defecography (2.3%) if follow-up were necessary (P < .001). Dynamic anorectal endosonography and dynamic MRI defecography show equivalent diagnostic performance in assessing pelvic floor disorders. However, because of its better tolerance and availability, dynamic anorectal endosonography may be preferable as the initial imaging procedure after clinical examination in the evaluation of pelvic floor disorders.

Anal vector volume analysis: an effective tool in the management of pelvic floor disorders

Different trials have investigated the role of conventional anal manometry in the diagnosis of pelvic floor disorders. The aim of the present study is to define the role and the effectiveness of vector anal manometry and vector asymmetry index scoring in the assessment of pelvic floor disorders i.e. fecal incontinence and obstructed defecation. Between 2005 and 2007, 387 patients underwent clinical and manometric evaluation in the Department of Surgery, University Hospital Tor Vergata, Rome, Italy, and were included in the present prospective cohort study. All the patients underwent clinical examination, Wexner incontinence scoring, and anal vector manometry and were classified into three groups. Group I included patients with normal resting anal pressure values (195 patients). Groups II and III consisted of patients with resting anal pressure higher and lower than normal values, respectively (90 and 102 patients, respectively). All patients were classified into asymmetric and non-asymmetric according to the vector asymmetry index using a cut-off of 20%. We investigated the correlation between anal asymmetry and pelvic floor disorders, i.e. fecal incontinence due to sphincter injury, rectal prolapse, and obstructed defecation. In Group III, the number of asymmetric patients was significantly higher than non-asymmetric ones (P < 0.0001). Asymmetry values were significantly higher in group III than in groups I and II considering squeeze (P < 0.0001) or resting pressures (P < 0.0001). Furthermore, there was a statistically significant association between anal asymmetry and both anal incontinence (P < 0.0001) and rectal prolapse (P = 0.0270). No such association was found between anal asymmetry and obstructed defecation. Anal vector manometry using vector analysis of resting and squeeze pressures is complementary to endoanal ultrasonography, as it provides information on anal sphincter function and integrity. The vector asymmetry index >20% correlates with fecal incontinence due to anal sphincter lesions. Therefore, anal vector manometry may be useful as an independent method of screening for pregnant women at risk of sphincter injury and for patients undergoing anorectal surgery with risk factors for incontinence, like previous anorectal surgery or a history of two or more previous vaginal deliveries.

Perspectives in urogynaecology: the surgical challenges ahead

In this short review the new developments in urogynecology are addressed. The number of patients with pelvic organ prolaps (POP) is rising due to the ageing population. Between 4% and 50% of female patients complain of urinary incontinence. POP is related to (vaginal) parity. Because POP develops many years after vaginal birth trauma and not in all patients, a hereditary factor changing connective tissue function is suspected. In the diagnosis of pelvic floor disorders, imaging (ultrasound and MRI) are used more and more frequently. Pelvic floor surgery has high recurrence rates up to 30%. Mesh augmented pelvic floor reconstruction is becoming more popular. Little randomised evidence is available to date, but slowly but surely more evidence accumulates supporting the use of mesh.

The Advantages of Volume Rendering in Three-Dimensional Endosonography of the Anorectum

Anorectal diseases require imaging for proper case management. At present, endoanal ultrasonography and endorectal ultrasonography have become important parts of diagnostic workup of patients with fecal incontinence, perianal fistulas, and rectal cancer and provides sufficient information for clinical decision-making in many cases. However, with the currently available ultrasonographic equipment and techniques, a good deal of relevant information may remain hidden. The advent of high-resolution three-dimensional endoluminal ultrasound, constructed from a synthesis of standard two-dimensional cross-sectional images, and of "Volume Render Mode," a technique to analyze information inside a three-dimensional volume by digitally enhancing individual voxels, promises to revolutionize diagnosis of pelvic floor disorders. By use of the different postprocessing display parameters, the volume-rendered image provides better visualization performance when there are not large differences in the signal levels of pathologic structures compared with surrounding tissues. The anatomic structures in the pelvis, the axial and longitudinal extension of anal sphincter defects, the anatomy of the fistulous tract in complex perianal sepsis, and the presence of slight or massive submucosal invasion in early rectal cancer may be imaged in greater detail. This additional information will bring an improvement for both planning and conduct of surgical procedures.

Comparative study between dynamic MRI and pelvic organography in diagnosis of pelvic floor disorders

To evaluate the clinical value of simultaneously combined pelvic floor dynamic MRI and pelvic organography in diagnosing female pelvic floor disorders and search for the best imaging model for diagnosing pelvic floor disorders. Thirty women with pelvic floor disorders received pelvic floor dynamic MRI and simultaneously combined pelvic organography including cystourethrography, peritoneography, vaginography and defecography. Clinical diagnostic value was compared between this two methods. The diagnostic accuracy of pelvic floor dynamic MRI and simultaneously combined pelvic organograph for cystocele,anorectal junction abnormal descent, pelvic floor hernia,uterocervical prolapse was 100%, 95.2 %, 86.7%, 85.7% respectively. Rectocele and prolapse of rectal were diagnosed by pelvic organograph in 12 and 28 cases respectively, while only 6 and 0 cases were diagnosed by pelvic floor dynamic MRI respectively. The mean examining time of pelvic floor dynamic MRI and simultaneously combined pelvic organography was (16 +/- 3)min, (34 +/- 9)min respectively (P< 0.01). Pelvic floor dynamic MRI combined with defecography is the best imaging model for diagnosing pelvic floor disorders.

Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders: pilot study.

Defecating proctography and more recently, magnetic resonance imaging have both been used for diagnosis in patients with pelvic floor dysfunction. This pilot study assessed the feasibility of dynamic transperineal ultrasound in a range of specific disorders affecting evacuation. A protocol of sagittal and transverse transperineal imaging was established defining the infralevator viscera and soft tissues and the margins of the puborectalis muscle. Dynamic measurements were possible for the extent of puborectalis shortening, the anorectal angle, and the movement during straining of the anorectal junction. Calculations were made of the depth of demonstrated rectoceles, the posterior urethrovesical angle, and the movement of the urethrovesical junction. Diagnoses were confirmed by proctography (where appropriate) and clinical examination. Transverse images of the anal sphincter were comparable with those obtained using endoanal ultrasonography. Sagittal images permitted the measurement of puborectalis contraction and the anorectal angle comparable with those obtained during defecography. Cystoceles were able to be diagnosed during closure of the posterior urethrovesical angle and abnormal urethrovesical junction descent during straining. Rectoceles, peritoneoceles, enteroceles, and rectoanal intussusception were readily identified using dynamic transperineal ultrasonography. Dynamic transperineal ultrasound is a simple, noninvasive way to assess dynamically the interaction of the pelvic viscera and their relationship to the pelvic floor musculature in patients with evacuatory disorders and pelvic floor dysfunction.

Dynamic MR defecography for diagnosis of combined functional disorders of the pelvic floor in proctology

Evaluation of magnetic resonance defecography in the diagnosis of pelvic floor disorders were examined prospectively. MRI was performed on a 1.5 T scanner. The rectum was opacified with 200 ml of ultrasound transmission gel. A sagittal single section T2-weighted gradient echo sequence with a temporal resolution of 1.1 second was performed. Changes of the anorectal angle and the position of the pelvic organs in relation to the pubococcygeal line were registered at rest, during straining, and during evacuation of the rectum. Patients with obstructed defecation (n = 15) showed prolapse of the rectal mucosa (n = 5), anterior rectocele (n = 8), pelvic floor descent (n = 5), enterocele (n = 2), and anorectal dyscoordination (n = 3). Individuals with stool incontinence (n = 15) had an anterior rectocele (n = 10), pelvic floor descent (n = 11), enterocele (n = 2), prolapse of rectal mucosa (n = 1), and a puborectal insufficiency (n = 1). Urine incontinence was associated with cystocele (n = 10) or normal findings (n = 4). In patients with unspecific symptoms (n = 6), anorectal dyscoordination (n = 4) and prolapse of the rectal mucosa (n = 2) were found. MRI was superior for the detection of enteroceles, cystoceles and pelvic floor descent compared with clinical investigation. Dynamic MR imaging supplies complex information in anorectal disease and thus improves proctoscopy.

ELECTROMYOGRAPHY OF THE PERINEAL FLOOR

Electromyography is the study of minute potentials produced by the depolarization of the muscle membrane; they may be useful in the diagnosis of pelvic floor disorders. Either surface or needle electrodes may be used, depending on the type of information desired. Innervation deficits may be indicated by abnormal potentials observed in resting or active muscle. Electromyography is also useful in assessing coordination between bladder contraction and sphincter relaxation.